>> the book is called high price. our guest is dr. carl heart and he not only is an author at 46 but associate professor of psychology and psychiatry at columbia university member of the nashua buys three council on drug abuse a board member on drug dependency and has done 22 years of research in narrow cycle pharmacology and it has been a pleasure
[laughter] having been on tour for the last two weeks and he has done a lot of these things. i guess we will talk at 20 or 25 minutes and then we will open up for questions. gary's book is about the making of the fifth revision of the dsm that comes out on wednesday. >> and it has received uniform positive reviews and everyone has piled onto the dsm. so who might offend the dsm and what does it mean that you cannot find anybody do defend the dsm?
>> i have been feeling sorry for them over two years. there are two answers to that question. why won't anybody defend that first of all, because those who produce the dsm don't have the chops to defend it. for post-modern philosophy to defend of poke full of signifiers that are not signified. >> let's stop there for one minute. explained that. >> i have never said that in the two weeks. >> but what does that signify? >> the mental disorders listed that drug czar aimed at and the research is supposed to be tied to and
the mental disorders that your psychiatrist is treating those by a every buddies understanding it is a myth or a construct it is a myth that guides the way we understand of world. one of the reasons every betty piles on to the dsm is because opening up to revision is opening up to the public knowledge psychiatrist had 30 years that it is a book of construct, not real entities. and depending on who you are, that news is either deeply embarrassing because it has staked your entire profession to be able to say you know, what mental disorders are or the enormous opportunity it is an opportunity to write a
book but somebody like the national institute of mental health has never liked the dsm and the like to see it disappear and it was an opportunity to say we know this is true we would like all of researchers to come to us we're leaving it for a younger and sexier lover. [laughter] >> the lover is called neuroscience and it is a tremendously tempting idea that we can decode human behavior and experience and consciousness and understand in terms of narrow circuitry and i reason that is a tempting idea to unlock the key to who we are. you no longer have to worry here understanding of human nature is controlled by politics or point* of view or prejudice or desire it
will always be as true as streptococcus bacteria under a microscope it is a dream i am not fond of but if indeed that is the case then whenever there is suffering there would be a way to decode and boil it down to the narrow circuits that causes it and treat it that is the duty if you are the drug company. >> but at the same time a the apa likes to say medicine isn't really medicine in the first place. >> that is a fair point*. the whole idea a disease is a form of suffering that has a biochemical cause, this is another myth is a big myth and a historical accident that pass to do with the
discovery of the germ theory of medicine that came 150 years ago and the idea that you could find the causes of suffering in cells or molecules of or whenever the unit was and when doctors were suddenly able to cure diseases that killed people routinely, strep throat killed children. syphilis affected maybe 40 percent of the people in europe at the turn of the 20th century. when weber able to do that that, they were able to attend a turnaround and enhance the power of madison and then this is we can turn any type of suffering into that type of illness. so when we say psychiatry can do that the fact is there is a lot of physical
disease we cannot find targets for either and more and more illnesses become problematic, automation is a good example. we don't really understand how that happens the medicine and functions on the bacteriologist all mont negative bacterial model and will run at a disease is caused by germs so in the american psychiatric association says that they are not wrong and it is possible there on the leading edge not lagging behind it dealing with the difficulties that will be much more complicated to take into account many more things besides molecular activity how income is distributed and how people experience their lives. >> one of the strategies is to say we used to use roman numerals now we switch to arabic numerals to be more like technology to have
5.one and 5.two to be a living document so what does that mean the dsm is a living document? >> nobody knows. i wish i could answer that question i have asked many times and i don't know and the idea is they will beta test but the problem is anybody who has ever bought a new program knows it is messy and unpredictable and it turns the consumers basically into guinea p.i.g.s. which is totally different with psychiatric and mental illness compared to the new act on your iphone. >> one of five favorites in the book is you take part of the clinical trial to determine the use of the new criteria.
can you talk about your experience with there patients to go through the epa guidelines? >> the apa conducted trials to road test the dsm and they did that by contacting clinicians to ask them to take patience through new procedure by which the symptoms would be assessed and i signed up to be one of those conditions and on the same day they told me they would not talk to me anymore the people running the field trials told me i was accepted as a clinician. [laughter] i may have something i can read about this. let me read about what it is like, the ada is somebody i
had never met before would run through these couldn't -- clinical trials but it was a disconnect between somebody who would come into my office, whenever her mental problems are suffering word and this computer test i had to give her coming in the book i call her claudia she showed up on a rainy night 20 minutes after frantic throat phone calls that i assured her they gps was correct for mayor she was to my building and as she wanted the hallways which she did not find until i went out to meet her she was easy to spot a tiny woman with the pixie here cut going from door way to doorway when i found her she pressed her hands together and balance slightly my a credibility was established by me knowing my way around my
building a gesture she repeated three or four times just after metacomet after she left i tried before the life of me could not have recalled what those comments might have been. might memory may have been lost in the details that poured out at top speed but being too busy to absorber distress and confusion, depression and anxiety and paranoia, her love affairs with men and women in the way she moved like a hummingbird just landing long enough to sip nectar than searching for the next flower before she was finished with the last. the most recent after tax than the males and aborted tressed a company to a hotel room only to find his girlfriend and for reasons she could not explain went ahead with the suggested sexual encounter with the girlfriend and she was afraid to is about to lose her job and maybe she lost a
ready but she was too afraid to ask your boss that she had been having sex but was leaving the company and his replacement was case and he would not exchange job security for sex not that this is what she was doing with the boss. those who need care and feeding and w those who need care and feeding and what she really wanted to know from me is what do do about the birds. it is like going through whitewater she may be skeptical but i was willing to do try anything and the diagnosis to grant me the ability to communicate efficiently to a least one clinician. so i was glad to offer the opportunity to participate in this study and if revisit in return and for reasons she never stated that most likely because she did not know how to say no to men she was glad to consent.
[laughter] we went through this whole thing and it took an hour and a half. i had to stop because it was going on for too long because you fill this out you push a button and it goes to another computer someplace else then it comes back 6.three on the scale and you are supposed to follow-up but everything would have to follow up the whole range. so i quit and then she would ask me what her diagnosis was. which is totally reasonable. i had no idea and even if i had or knew how to get this confusing woman there was still 30 pages to get through box after box to check about her self and interpersonal function and her negative aspect of the
and inhibition and the demands of her trades and hundreds before i could make my final diagnosis and with the authority vested in me as an untested cater of the american psychiatric association decided which construct had be there denigration nor worship that could still be measured between zero and four to be taken seriously to mortgage payment may be round of medication and as a serious anyone would accuse them of which placeholder would take her weight and height and blood pressure and her childhood that no matter what diagnosis i settled i would not tame her but the raw material of the apa profitable mill. [applause] >> what was the result of the clinical trial?
>> that there were 5,000 of us collaborating i just watched inglorious bastards on the train and they were collaborators. [laughter] and there were 5,000 of us to begin with the only 600 finished the trial. why was that? you just heard why. and it turned out when they finally unveiled the results at the meeting at the apa annual meeting last your the only thing they really wanted to know if we liked doing it it was thumbs up like facebook. [laughter] does facebook have a thumb down? that was the result also the clinical trials of academic medical centers that were more serious not just collaborators but they we're doing the diagnosis and they
discovered that the dsm-v would not be reliable. the results were embarrassing. at least in the american psychiatric association. >> the foundation of the modern dsm was with reliability so how did this happen? >> in the 1960's and 70's once again it is of the embarrassment. and it makes a better diagnostic. the crises occurred and it was caused when a few things happened when homosexuality
was a dizzies up and tell three years of apa meetings were disrupted by gay activism then they came out as gay and force them to remove it from the dsm and also there were a couple of embarrassments with high-profile studies where of a group of graduate students check themselves in to mental hospitals by going to the emergency room and say i would hear the word thud in my head and it will get them 56 days to get them out and then a steady that showed doctors contend with the same patient would consistently come to a different diagnosis and british doctors of manic depression and american is schizophrenia. it is training.
it turned out to the psychiatrist could not agree , what mental illness a person had and then when they could agree they could not tell you if it was a mental illness. so they decided the way to address this problem was to develop a checklist that constituted mental disorders to say to make them reliable so they could look at the same list of symptoms to come to the same conclusion and that is what happened with the dsm three that came out in 1980 and it was reliable they made sure that they would cook the books to make it so it was really hard for any to a psychiatrist not to agree to use the structured interview that was bound to come to this certain conclusion and able to do this to make the
diagnosis more reliable and they were because if you give somebody else lest it makes it more reliable but what they never said they did why we have the problem three years later is they never make them a valid and the major depressive disorder ninth symptoms of major depression any five of them you can be diagnosed. they never said how we knew it was really a disorder or a disease. and they planted the question down the road. >> occasionally you have managed to say something nice about psychiatry. [laughter] >> i will not do it again. [laughter] summary say you think that kasper's was the most successful disorder that psychiatrist managed to
invent and what has happened to that? >> think about what is a disease it is not the idea from the biochemical pathology. a disease is suffering that society decides to devote resources to relieve famine make that distinction through biology. it is a backdoor it is scientific so there is no value there for you deserve the resources. what happened with kasper's the apa play into dsm formed in the most immediate lee some people call it the epidemic many people turned out to qualify and what happened is all these people ended up with resources with community, school resources and maybe the most
pre-sources of all, tolerance and suddenly not just these weird and awkward people but they had an identity. no success should go unpunished and then it became another embarrassment and in this case with all these people with kasper's disorder and but the real pressure i'm sorry run a little awkward but the real pressure was coming from the school system that would pay for the service but from that apa point* of view it looks like the as first diagnosis -- the asbergers diagnosis was too easy to get so they decided to take it out so all people will be cured of. [laughter]
just like how gay people were cheered they will just be deleted. the interesting thing about that story when the apa announced their intentions they were flooded with complaints from the people with asbergers and they were surprised. the four men who ran the committee who ran this told me she was surprised to hear that people had made an identity around us versus order and they were surprised to hear they did not want to lose that. she was shocked so the surprising part about that to me is they did not understand that is what psychiatric diagnosis does. they know it is a stigma and makes people feel bad but they understand they are constructing identities which is a shocking blind spot. >> one of the new things the new dsm has done is the
medicalized that comforted people and obviously the other side of the critique is that over medical is nation of room also can you talk about your favorite new disorder in the dsm? >> there is a few. but i think the most serious is called disruptive mood regulation that originally would be called distemper but it makes people think it would be applied to too many children who had temper tantrums rather than change the diagnosis they changed the name. everything else stayed the same that was invented in order to solve the problem but to many were diagnosed with bipolar disorder to put on anti-psychotic drugs it is a terrible problem rather
than say you cannot diagnose kids with bipolar disorder which would have been simple is they created a new diagnosis because god forbid they should not have a new diagnosis so now these children will qualify for which to me is like the lady swallowing a spider to kill a fly the only justification is then they don't get the anti-psychotic medication but what is important to know is most prescriptions for psychiatric drug czar written without a psychiatric diagnosis. three-quarters are written without a diagnosis and more hype than half of the 80 ht drugs there is nothing to stop the doctor the biggest reasons is so many are written by family doctors they don't need to take the
time that many don't want them to go into that chart and unless they are challenged why are they prescribing this medication they will not provide a diagnosis. one is about identity that is what the dsm does also about drugging the population that is in directly related and and this comes from the dsm but the prescriptions don't. >> you are right how big pharma has spent pulling back from there support from that apa and why they have become so financially dependent on the dsm. >> yes. first of all, the apa was embarrassed and they had to kick the moneychangers out
of the temple and in this case the pharmaceutical industry and the apa had to create some distance because they were caught childhood bipolar was an invention of the drug company for the most part. there are not conspiracy's out there because you don't need them. you have space some. [laughter] maybe that is a different conspiracy but people call me paranoid. [laughter] they made some distance but another part of the form of a psychiatric break up is the pharmaceutical companies don't want anything to do with the psychiatric drug they are walking away from those. that is in part the faults of the dsm because the drug industry is forced to get the drugs approved for dsm
disorders that do not exist. when they go to get them approved, they barely qualify. not only because the drugs work or because we are complicated the drug that works for you will not work for me. you also don't know what to measure it against. there is a disconnect like free drugs for diseases don't exist? so they got out of the business. >> this is a book about the definition of the disease that like we like to define
a sickness in a circular way that ms. somebody does something terrible we jump to call them six. you read somewhere that and also that you believe in evil. >> you sound like satanic. [laughter] >> can you talk the difference about sickness and evil? >> some academic shed some days the down with the dsm to figure out what the idea of the good life is that is behind the dsm. much these disorders do is substitute for moral judgment.
we have a reflex of something bad happens we assume somebody is mentally ill. i write about pedophilia and you think that guy is really sick. is the? or is he just an opportunist? is he just somebody who has a moment where he can get what he once? that is the question the apa has been fighting all along. is a really true every time somebody does something that registers as bizarre beyond pale that they are sick? i myself believe the answer has to be no. i think our moral discourse is impoverished by the tendency to make diseases and it is the unfashionable word but there is evil.
>> when i was younger i was diagnosed with a ph.d. and then i realize this is a bunch of buullshit like his ear and listened to without jumping up to sing all over the place. and i have noticed they diagnose these 10 kids and when i was younger you diagnose the kid who has an interest in something or just has a lot of energy so you must have a ph.d. and that is why like you would go over asbergers and maybe this isn't the right example but like they tried to
market that turkey. [laughter] like a transmitted diseases to not make such a a big deal until they realized they could market the drug. but then they realize they can market the drug. >> is called disease maundering serving the interests including patients but they could make money off of that. and with the child diagnosis 11 kids are developing to socialize.
>> and the dsm over the last 30 years the prevalent disorder surprisingly has not gone up except with one group which is children. all of a sudden there's a lot of diagnosis and nobody really knows so what is the purpose of the diagnosis often so a kid that has tea to is a reason for that child to be put on a stimulant. i will tell you a story. a child who was relatively challenge. less now than he was but when he was nine or 10 i
heard from so many people that he should be on stimulants. they never quite said adhd maybe you should think of the course of stimulants. says you can imagine if it gets to me, how strong of a message i finally said okay you say i'm destroying my child and not giving him stimulants. so i go to the doctor and he writes a prescription for 10 milligrams a matter of and i thought before i give this to him i think i will see what this is about. so i snorted it. [laughter] i to get. at the time i weighed 50 or 60 percent more than he did.
he is now six ft. tall. [laughter] and i was absolutely shocked. i was also very high but i could not believe it. i am going to give this to a kid? it was appalling. and he did not take it. i'm telling you that because the obvious point* they are given out to casually but the more subtle point* man once you start down the road there is no turning back a kid with a developing brain and they have no idea the effect of the drug although a amphetamine has been around a long time in so to the extent it is driven by the desire to manage drugs i don't think it is a good
idea. this is part of the dsm backlash also the recognition too many children being given drugs and nobody understands. >> i have a question the dream of a neuroscience. >> i was reading the other day a letter written by a psychiatrist that said the new york review of books did in a say. >> don't you love those exchanges? that is pure entertainment. what did he say? >> he defended matt until illness with the origen and
everyone who has had a drink knows that behavior has its roots in a mental state. >> that is not a terrible argument that taking drugs proves that brain chemistry is really important. every day i thank god for my brain chemicals i assume consciousness would be impossible. what has not been done convincingly and maybe never will bring chemistry is necessary and sufficient
condition for experienced we no brain damage stroke whenever will tell you that. not just a philosophical point* but before you go to a model mental illness is understood you have to either prove that which i believe is impossible for i don't know that i will act like it is true with this scientific economic weight behind the assumption so this drug that i am giving you will change your brain chemistry but i don't know how and i don't know why and where in the long run which difference makes the dream
of neuroscience is a dream it could come true the same way that we think of ourselves as individual agents in the world free and equal but historically we have changed who we are over the millennia. that could happen again we to wake up 500 years from now to be a molecule. >> what is the name of the story? i don't know the name of it that we could wake up in that world. this is where i become grateful for my mortality. [laughter] >> how would i be convinced? i don't know if i could i
not know if it could be proven. i have done plenty of things that are convincing demonstrations that brain chemistry is really important when you mess with it really changes things. >> see his first book of he began the reading with this of all types of things and that you tried to put it through me and let's say that dsm did not exist but is it just for people who
are having trouble to function? that i screwed this up the other way to talk about it and because there are a lot of people who are somewhat functional, and not quite together and what i get out of that question is in the absence of these labels how would mental-health the practice? does that sound fair? >> that is the one end of the continuum of mental health but the difficulties
are real. >> the question is could we function without the diagnosis? the answer is yes and in fact, a therapist functions without a diagnosis of the time the only value to a therapist is to get paid. this is the real scandal by the way and i speak as a therapist the only reason most of us use it is to get paid. i, not just be i interviewed a former president of the american psychiatric association who told me that how you use the dsm in your practice? he said the only difference is i got paid.
so the value, if there is one is to have a common language that is the justification to give people a common language but why is it have to be this sucky language of dsm? we can't just communicate in english? i cannot just say you have a lot of the year or sadness? we have perfectly good words so i don't think the whole thing falls apart but the economics fall apart but the way that drug czar treated we would have to go to a completely different model and by the way the dsm isn't going anywhere it is a necessary evil compared to a colonoscopy.
[laughter] one of the things that you have to endure to go on but what is really interesting right now with all of the piling on is that there are no defenders you have a situation when they finally figured out astronomy wouldn't work and if you look up in the sky and the star is and where it is supposed to be that was a story but that was before copernicus comes along. what do you do? i don't know. one thing that could be done is you could make one arbitrary distinction between severe mental illness and the rest to get it focused on severe mental illness but my fear is it would be looked at that is the real medical stuff when it is obvious there are
homelessness and mistreatment and all sorts of other things that are not medical strictly speaking that goes into schizophrenia but make that distinction and focus resources there what that would mean is therapist like me would have to detach ourselves from the medical model and make less money. but you cannot have it both ways and we do. we have it both ways i am by 18 really hard that hand that feeds me. the i try not use this method and have people pay me directly but we make less money and we would be less medical and have less prestige but that may be okay was that cynical? [laughter] did you have something you wanted to say?
>> talking about the influence to talk about the unexpected consequences that were formed is it analogous? >> absolutely one of the things that will have been is with the real popular diagnosis is that it starts to frame the way that you think about patients one of the things that happened is i was diagnosed with major depressive disorder and i found that powerful in terms of power thought of myself but also started to frame the way how we thought about people coming to see me and not always in a good way to it gives too many preconceived ideas of a
behavior or comment and what it is about. >> can i read something else? the question has come up a few times i will tell you how this works for me. what happens in therapy is most of the therapist i know don't take the book seriously. table, before five diagnosis then they forget about the rest of the books they paid $200 for a book you should use it more. [laughter] so at the top of my list stands for adjustment disorder i am sure you can see just on its name why it is popular with clinicians it sounds innocuous which makes it goes down easy with
patients and employers or others who may have occasion to scrutinize the medical history and offers flexibility but it doesn't have a special place in my heart because it was my own first diagnosis were the first one that i knew about. sometime in their early eighties in my early 20s and the dsm in the third edition and to remember why i wanted to be in their pure white talk about but i do remember my father paid for it probably hoping would discover myself chosen circumstances living alone in a cabin in the woods were something that could be cured. when i was being treated for was not back to the landed disorder or why don't you grow up already disorder but i discovered one day but adjustment disorder i definitely wasn't adjusting and by calling my lifestyle and illness they had passed
judgment with the problem resided but i noticed for the first time i was going to these weekly appointments in the doctor's office in a building adjacent to my childhood pediatrician but did not smell like alcohol nor did it seem related to the probes i suffered next door so the discourse stood out with the diagnosis was undeniable i was a medical patients and eventually curative maladjustment not by there be but a family to that resulted in my grandfather's being relieved of the farm he inherited from his mother that was the land on which i built my home so i was effected and my cabin was bulldozed and it was turned into a mansion and it became necessary to earn a living over the many adjustments had to make diagnosing people in order to secure and income was one
of the strangest not because the dsm label seemed insufficient and the criteria and so they know with the rich and disturbing conversation that was occurring in my office but also because of the bad faith involved i did not mind if they would collude with insurance companies are brought them in to explain what diagnosis giving them to read there criteria and occasionally offering them a choice but the fact we would share the why did not make any last. everyone has the adjustment disorder on the ground it is not much of an illness toward treatment and at which point* the patient often contracts a case of something worse like manic depressive disorder i prefer to mix it up a little but i prefer moseley had to do business with insurance
companies. of course, that means i get paid less money since not everyone can pay my rates so i give people a break to steer clear of the business it is ironic a professional once dedicated to the pursuit of psychological truth is dependent on this for survival but i suppose any system guided by the invisible hand of the markets is bound to be gained and the dsm whatever its flaws is proven to be a superb play book. [applause] >> we are done. thank you very much. [applause]
>> the book called freedoms teacher is a biography of a lifelong educators, social activists and civil rights activist. and my book is about her educational activism both prior to and during and after the civil rights movement. i am interested in telling her story because she was a very important person in the civil rights movement but also important before that. she was nearly 60 years old
at the time she did what she was most well-known for this is an education program, a citizenship school such as i got into researching this book i thought what did she do between 20 and 60 that prepared her to do do this and to tell us of the deeper roots of the myth and the women's role and her schools for primary sites of women activism during the movement. looking at the one figure was a way to tell a longer story of the civil-rights movement also black women's activism over the 20th century. born in charleston 8098, her father was a slave. her white woman was every mother born in charleston raised in haiti and she started her teaching career
1916 on john's island. she continued her career and urban schools in south carolina and all of her teaching career in south carolina then in 1956 the state of carolina passed a law to forbid state employees from belonging to subversive organizations such as the naacp and she lost her job and her retirement and then she developed the citizenship education program to be used during the civil-rights movement. the citizenships schools were designed to enable african-americans in this house to learn shoe read and write to pass a literacy test to register to vote so they had a practical literacy component but
beyond that part curriculum taught people about political literacy and economic literacy. so for her, the first hurdle was registering to vote but the real job would come to understand citizenship responsibilities and then using the vote to bring improvement to your local community. the first goal was to pass the literacy tests and register to vote. every state had a different test that required applicants to read a section of the state constitution to the satisfaction of the registrar. it was always a white person who could find any way to say that was not good enough but you also had to sign your name on the form so
that was the first death and a concrete goal and once people were able to do that they could imagine doing other things as well. practical literacy gave people the self-confidence that they had otherwise lacked because there were dependent on other people because they could not read for themselves. house citizenships schools work, highlander oversaw them from 1957 through 61 at which point* it chance for the program to the southern christian leadership conference which was dr. king's organization and from there it spread throughout the south. how they did this was community organizers identifying people who were most likely make good teachers in there community and they've looked for people with a ph.d. mind to do not have a chance to get an education so it was very grass roots they would bring
people to the week-long workshop to teach them how to teach the class's and the educational levels and how to identify what needed to be done in the community and start to work on them from above. another part of the genius of the citizenship schools is that few moderate white southerners could argue against teaching semiliterate african americans to read and write segregation and provides camouflage the white people don't know what is going on in that classroom. only people that pass through the school that but what they've turned into practice in my day figure out this is a source of the problem.